支气管扩张剂作用的分子药理机制.ppt

单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,支气管扩张剂作用的分子药理机制,上海市瑞金医院 黄绍光,Control of airway diameter,Epidemiology,/pathology,自主神经参与调节许多气道功能，影响气道平滑肌，粘液分泌，血管、微血管通透性，炎症细胞的迁移和释放。神经机制在气道炎症疾病中可放大或调节炎症反应，其中胆碱能神经是引起气道收缩的主要因素。,Increased maximal airway narrowing,in asthma,Thickening and increased stiffness,Inner airway wall,Hypertrophy and increased contractility,Airway smooth muscle,Loss of,elastio parenchymal,recoil,Normal,COPD,Disrupted alveolar,attachments,(emphysema),Mucosal,inflammation,and fibrosis,Mucus,hypersecretion,Airway held open by,alveolar,atteachments,Airway obstructed by,lossof,attachments,Mucosal inflammationand,fibrosis,Mucus obstruction of lumen,Airway pathology in COPD,抗胆碱能药物,2,-受体激动剂,茶碱,平滑肌细胞,收缩舒张,cAMP,AMP,M1,M2,M3,三大类支气管扩张剂作用机制,cGMP,肾上腺素能受体激动剂做为最主要的支气管扩张剂在支气管哮喘及慢性阻塞性肺病（,COPD）,等慢性气道疾病的治疗中得到了广泛的应用。,b,2,-Agonists,Eosinophil,Mast cell,Cholinergic,nerve,b,2,-Agonists,Smooth muscle,Acetylcholine,Histamine,LTD,4,-,-,-,-,?,所有,受体激动剂都是,苯乙胺的衍生物,，其儿茶酚环上的羟基位置与作用持续时间相关，改变羟基位置，如间羟异丙肾上腺素、或加上其他基团作为替代物，如沙丁胺醇（配基糖苷类），可防止儿茶酚氧甲基转移酶（,COMT）,的代谢；而,N,端的结构则关系到作用的选择性，其取代基越大对,受体的选择性就越强，而,受体的活性就下降（如异丙肾上腺素），还可促进对单胺氧化酶（,MAO）,的抵抗，进一步增加,N,端的结构则对,2,受体的选择性更强。,b,受体激动剂的母核,a,b,CH,CH,NH,苯乙胺核,b,2,-agonists,化学结构,Formoterol,:medium side chain,Salbutamol,:short side chain,Salmeterol,:long side chain,O,H,N,H,O,C,H,C,H,2,N,H,C,H,C,H,2,H,O,C,H,3,O,H,C,H,3,C,H,C,H,2,N,H,C,H,2,O,H,C,H,3,C,H,3,C,H,3,O,H,O,H,C,H,C,H,2,N,H,C,H,2,O,H,O,H,O,O,H,CH,2,CH,2,CH,2,CH,2,CH,2,CH,2,CH,2,CH,2,CH,2,CH,2,人类,b,2,肾上腺受体的分子结构,糖基化,413,氨基酸,b,2,激动剂结合点,TMD,I,胞浆,COOH,II,III,IV,V,VI,VII,4,3,2,IL1,EL1,2,3,细胞外,细胞膜,NH,2,棕榈酰化榈,受体是通过细胞内腺苷酸环化酶增加而介导其活化过程。,受体的信号转导系统是核苷酸调节蛋白,Gs，,受体和腺苷酸环化酶的偶联是通过三维体,Gs,蛋白，包括,、,亚单位，,G,蛋白可以兴奋（,Gs）,或抑制（,Gi,）,腺苷酸环化酶，因此可以增加或减少细胞,cAMP,的浓度。,b,2,激动剂激动,b,2,受体,(,b,2,AR),程序图,Blocked by,CHARYBDOTOXIN,Cell,membrane,a,s,b,g,a,s,b,g,b,2,-Agonist,b,2,AR,G,S,G,S,ATP,Cyclic 35AMP,Ca,2+,-activated K,+,channel activation,PI hydrolysis,Na,+,/Ca,2+,exchange,Na,+,/K,+,ATPase,MLCK,PKG,PKA,AC,K,+,G,S,：,兴奋型,G,鸟核苷酸结合蛋白（,Gs）,；AC：,腺苷酸环化酸；,PKA：,蛋白激酶,A,PI：,磷酸肌醇；,MLCK：,肌凝蛋白轻链激酶,Barnes PJ AJRCCM 1995,Anderson,.,Life,Sci,1993,Aqueous,biophase,Cell membrane,with,2,-receptor,Salbutamol,Hydrophilic,Short duration,Fast onset,Formoterol,Intermediate,Long duration,Fast onset,Salmeterol,Lipophilic,Long duration,Slow onset,微动力弥散理论,福莫特罗,中度亲脂性,长作用,起效快,微动力学,微动力学,沙美特罗,亲脂性,长作用,起效慢,油/水23000/1,膜吸收(,methachaline,/histamine protection=,Mast cell,stabilising,effect,Allergen,Adenosine,Histamine,LTD,4,Indirect,Mast cell,Histamine,Methacholine,MAST CELL,b,2,-DRENOCEPTIORS,Direct,Airway,Smooth muscle,b,2,-Agonists,EFFECT OF INHALED,b,2,-AGONWISTS ON,PLASMA EXUDATION IN AIRWAYS,Guinea pig trachea,Formoterol,Salbutamol,b,2,-Agonist,Histamine,Plasma exudation,?,control,70,60,50,40,30,20,10,0,Ptopranolol,Formoterol,Contraction(%control),e-NANC,Venceen,G et al:J,Appl Physiol,1992,100,80,60,40,20,0,EFFECT OF FORMOTEROL ON AIRWAY,SENSORY NERVES,Guines,pig,bronchiinvitro,EFS:40v,0.5ms,6Hz,SP,SP,SP,SP,Sensory,nerve,b,2,-receptor,Smooth,5P,减敏机制,包括三个主要过程：1.受体从腺苷酸环化酶上解偶联；,2.解偶联的受体从细胞膜上内陷；,3.内陷后的受体磷酸化。,P,P,P,P,P,P,Cell membrane,B,Arrestin,COOH,BARK,(GRK),a,s,NH2,b,2,-Agonist,cAMP,PKA,PKC,PTK,b,受体磷酸化，导致受体功能缺失。,磷酸化过程中，通过,b,2,受体特异激酶活化，使受体与,G,蛋白介偶联,该 过 程 涉 及,CAMP,依赖蛋白激酶,A(PKA),b,肾上腺素受体激酶,(,b,ARK),和 其 他,G,蛋 白 受 体 激 酶(,GRK),B,2,AC,DOWN-REGULATION,Cell membrane,mRNA,Nucleus,B,2,-Receptor Gene,CREB,ATP,cAMP,PKA,b,2,-Agonist,B,2,a,s,g,B,P,P,cAMP,PKA,CREB,B,2,mRNA,STABILITY,TRANSCRIPTION,UNCOUPLING,发生在接触激动剂后数小时,可能是抑制了受体基因的转录或是增加了细胞内,mRNA,转录后的分解代谢,细 胞 表 面 受 体 数 目 减 少(下 调 现 象,),受体从细胞膜的内陷，引起细胞表面受体某种程度的缺失，该过程又称为隔离。,CNS,Nodoseganglion,Laryngeal,Esophageal,afferents,C fibre,A fibre,C fibre receptors,Irritant receptors,Airway irritants,mediators,Airwayepithelium,Vagus nerve,Parasympathetic nerve,ACh,Parasympathetic ganglion,ACh,ACh,Submucosal,gland,Inflammatorycell,Cholinergic Pathways,Barnes PJ(1999),P,P,Uncoupling,Down-regulation,Reduced,adrenergic,responsiveness,B,2,G,s,AC,PKC,PLC,R,G,q,IP,3,Dlacylglycerol,Ca,2+,Infammatory,mediator,Acetylcholine,b,2,-agonist,炎 症 介 质，乙酰胆碱及,M,受 体 的 关 系,+,+,+,-,节前神经,副交感神经节,N,M1,节后神经,M,2,ACH,M,3,气道平滑肌,胆碱能受体,ReceptorLocation in Human Lung,M,1,Autonomic ganglia,Submucosal,glandsAlveolar walls,M,2,Post-,ganglionic,parasympathetic nerves,M,3,Airway smooth muscle,Submucosal,glandsEndothelial cells,M,4,Not detected,M,5,Not detected,Muscarinic,Receptors in the Lungs,ParasympatheticPost-ganglionic Airway ganglioncholinergic nervesmooth muscle,M,1,M,2,M,3,AgonistMcN-A-343Pilocarpine,AntagonistPirenzepineGallamine4-DAMP,TelenzepineAF-DX 116HHSiF,Methoctramine,Muscarinic Receptor Subtypes,M,1,M,2,M,3,Pre-ganglionicnerve,Parasympatheticganglion,Post-ganglionicnerve,ACh,Airway smoothmuscle,Nicotinic receptors(+),M,1,receptors(+),M,2,receptors(),M,3,receptors(+),Muscarinic Receptor Subtypes in Airways,Barnes PJ.,Eur Respir,Rev(1996),抗胆碱药物,神经机制在气道炎症疾病中可放大或调节炎症反应，其中胆碱能神经是引起气道收缩的主要因素。它表现为迷走神经张力增加，乙酰胆碱释放增多，作用气道平滑肌细胞膜上的,M3,受体，通过偶合,G,蛋白（,GP/GQ）,使磷脂酶,C,活化，后者促使二磷酸肌醇转化为三磷酸肌醇，从而使细胞内钙离子释放，导致平滑肌收缩，乙酰胆碱还作用于,M2,受体，通过耦合抑制性,G,蛋白（,Gi,），,降低腺苷酸环化酶的活性，从而减少,cAMP,的生成，胆碱能拮抗剂的应用，有其重要意义。,抗胆碱药物,有效的支气管扩张剂,1,2,通过抑制胆碱能受体来防止支气管收缩。,作用时间长于沙丁胺醇,1,异丙托溴铵,:4-6,小时,噻托溴铵,:24,小时,2,适合用于维持治疗,和其它支气管扩张剂一起使用，可增加运动量和改善症状及生活质量,2,3,1.,Pauwels,et al.2001,2.,Casaburi,et al.2002,3.,Vincken,et al.2002,正常,COPD,迷走张力,迷走神经,乙酰胆碱,抗胆碱能药物,阻力,1/半径,4,COPD,没有支气管,痉挛时也可明显,降低气流阻力，,缓解呼吸困难。,COPD,稳定期，胆,碱能张力为气流,阻塞主要可逆因,素。,-,Peter J.Barnes,“,Theoretical aspects,of,anticholinergic,treatment,”,异丙托溴铵,的作用不仅限于解除支气管痉挛,调节胆碱能张,力，有效舒张气道。,爱全乐与气道平滑肌,上,M,受体(毒蕈碱受,体)结合，阻断由胆,碱能神经引起的支,气管痉挛,支气管痉挛,胆碱能阻断剂,胆碱能阻断剂解除支气管痉挛的机制,P,P,Uncoupling,Down-regulation,Reduced,adrenergic,responsiveness,B,2,G,s,AC,PKC,PLC,R,G,q,IP,3,Dlacylglycerol,Ca,2+,Infammatory,mediator,Acetylcholine,b,2,-agonist,b,2,受 体 激动剂和 抗胆碱能药物,茶碱,相对其它支气管扩张剂来说，应用的较少,仅当吸入支气管扩张剂无法使用时才考虑使用缓释茶碱,适度的支气管扩张剂,在治疗剂量范围内可常见有副作用,治疗指数窄，因此其它支气管扩张剂优先考虑,和许多药物有相互作用,吸烟能影响茶碱的代谢,Pauwels,et al.2001,茶碱的支气管扩张作用是通过抑制磷酸二酯酶（,PDE）,而产生的，该作用打断了细胞内核苷的循环途径，从而使细胞内环磷酸腺苷（,cAMP,）,和环磷酸鸟苷（,cGMP,）,的浓度升高。茶碱是一种非选择性,PDE,抑制剂。,Theophylline,as an inhibitor of,phosphodiesterases,Cyclic,adenosine,monophosphate,Agonist,Receptor,Guanylate cyclase,Guanosine,triphosphate,Cyclic,guanosine,monophosphate,Guanosine,monophosphate,Agonist,Receptor,Adenylate cyclase,Adenosine,triphosphate,Adenosine,monophosphate,Protein,kinase,A,Inflammatory cell inhibition,Protein,kinase,G,Bronchodilatation,Theophylline,Phosphodiesterase,3,4,Phosphodiesterase,5,Inhibition,Inhibition,腺苷酸受体抑制剂（包括,A1,和,A2,受体)，这提示了其支气管扩张作用的基础，,增强儿茶酚胺的释放，茶碱可增加肾上腺髓质分泌肾上腺素,Multiple action of,theophylline,in asthma,Eosinophil,T,lymphoctye,Mast cell,Macrophage,Endothelial cell,Airway smooth muscle,Bronchodilatation,Mechanism?,Effects?,Bone marrow,Diaphragm,Sensory nerve,Phosphodiesterase,Mediators,Mediators,Mediators,Neuropeptides,Leak,Migration of,Lymphocytes?,Numbers,Trafficking?,Cytokines?,Strength,theophylline,联合治疗,联合不同作用机理和持续时间药物进行治疗可以增加支气管扩张的程度，而副作用相等或更少,1,已确定的联合用药,:,短效,2,-,受体激动剂,+,短效的抗胆碱剂,新的联合用药,:,长效的,2,-,受体,激,动剂,+,吸入激素,1.,Pauwels,et al.2001,急性炎症,慢性炎症,结构改变,急性炎症,激素治疗的,应答状况,时间,哮喘炎症过程,Barnes PJ,Effect of wall area on airway resistance during,Airway smooth muscle shortening,R=airway resistance,ASM=airway smooth muscle,Wall area=20%,R=1,R=1,Wall area=40%,R=1.8,R=80,R=7.8,30%,ASM,shortening,ASM,shortening,30%,症 状,炎 症,致 敏,重 塑,气道高反应性,激发因子，气道高反应性及哮喘症状的关系,序贯,激发因子,气道炎症,BHR,可变性气道堵塞,症状,分离旁路,激发因子,气道炎症,BHR,症状,可变性气道堵塞,平行,激发因子 激发因子,气道炎症,BHR,气道上皮 可变性气道,损伤 堵塞,症状,ASTHMA CONTROL,Airway Smooth,muscls,Mast cells,Plasma leak,INFLAMMATIONS,Genes,Atopy,Environmental,factors,CPRTTCDSTERPODS,LA,b,2,-Agonists,SYMPTOM,CONTROL,Corticosteroids,Virus?,AIRWAY,HYPERRESPONSIVENESS,Macrophage,Eosinophil,T-lymphocyte,b,2,-Agonists,BRONCHOCONSTRICTION,Treatment of asthma:cellular effects,Antigen,Virus?,Adenosine,Exercise,Fog,Mast cell,Airway smooth muscle,Cellular effects of,glucocorticoids,CORTICOSTEROIDS,Eosinophil,T-lymphocyte,Mast cell,Macrophage,Dendritic,cell,Numbers,(apoptosis),Cytokines,Numbers,Cytokines,Numbers,Inflammatory cells,Epithelial cell,Endothelial cell,Airway smooth muscle,Mucus gland,Cytokines,Mediators,Leak,2,-Receptors,Mucus,secretion,Structural cells,Cytokines,Molecular Mechanism of Steroid Action,mRNA,GR,b,hsp90,Cytokines,Adhesion,mols,Enzymes,Lipocortion,-1,b,2,-,Adrenoceptors,GR,Corticosteroid,Nucleus,+GRE,-GRE,Steroid-responsive,Target genes,EFFECT OF STEROIDS ON,b,2,-ADRENOCEPTORS,GRE,GRE,GR,E,b,2,-Receptor gene,Glucocortiaid,receptor,Nucleus,b,2,AR,mRNA,Corticosteroid,激素与,激动剂的协同作用示意图,b,2,-AGONISTS ACTIVATE GLUCOCORTICOID RECEPTORS,b,2,-Agonists,Nuclear,localisation,of,glucocorticoid,receptors,Gre,binding,Blocked by,propranolol,Mimicked by,cgclic,AMP,expression of a steroid,Inducible gene(P21,(WAF1/CIP1),),Eickelberg,O ct al:J,Biol chem,1999,A,FR,0 0.5 2.5 4 6,0 0.5 2.5 4 6,0 0.5 2.5 4 6,0 0.5 2.5 4 6,FR,B,GR/GRE,complex,unspecific,band,freeprobe,GR/GRE,complex,unspecific,band,freeprobe,+,fluticasone,+,dexamothasone,+,salmeterol,+,salbutamol,EFFECT PF,b,-AGONIST ON GR NUCLEAR TRANSLOCATION,100,75,50,25,0,Control,Human airway smooth muscle cells,P0.01,Bud,Ratio of,cytosolic,:nuclear,Carbitrary,O.D.units,Control,Budesonide,10-,9,M,cytosol,nucleus,GR,GR,Roth M et al:ATS 2001,EFFECT OF,b,-AGONIST ON GR NUCLEAR TRANSLOCATION,100,75,50,25,0,Control,Human airway smooth muscle cells,Bud,Ratio of,cytosolic,:nuclear,Carbitrary,O.D.units,P0.01,Form,Form+,Bud,Control,Budesonide,10-,9,M,cytosol,nucleus,GR,GR,P0.04,P0.01,Kom,S et al,Eur Respir,J 2001,互补的作用机制,症状/恶化,吸入激素,Adapted from,Bousquet,et al.,Am,J,Respir Crit,Care Med.,2000;161:1720-1745.,平滑肌,功能障碍,气道炎症,炎症细胞的渗出/活化,粘膜水肿,细胞的增殖,上皮损伤,基底膜增厚,支气管狭窄,气道高反应性,过度增生/增大,炎症介质释放,长效,2受体激动剂,b,2,-Agonist,Bronchodilatation,INTERACTIONS BETWEEN,CORTICOSTEROIDS AND,b,2,-AGONISTS,b,2,-,Adrenoceptor,Glucocorticoid,receptor,Corticosteroid,Anti-inflammatory effect,Effect of,corticosteroids,on,b,2,-,adrenoceptors,Effect of,b,2,-agonists on,glucocorticoid recptors,Thank you,Thank you,